When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

Determine apical pulse rate and rhythm.

Observe color and amount of urine.

Compare muscle strength bilaterally.

Assess strength of deep tendon reflexes.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the most important intervention because a high serum potassium level can cause cardiac dysrhythmias, which can be life-threatening. The nurse should monitor the client's heart rate and rhythm closely and report any changes or abnormalities to the healthcare provider.

Choice B reason: This is not the most important intervention because the color and amount of urine are not directly related to the serum potassium level. The nurse should assess the client's renal function and fluid balance, but these are not the priority assessments.

Choice C reason: This is also not the most important intervention because the muscle strength is not the most sensitive indicator of the serum potassium level. The nurse should evaluate the client's neuromuscular status and watch for signs of weakness or paralysis, but these are not the priority assessments.

Choice D reason: This is another incorrect intervention because the deep tendon reflexes are not the most reliable indicator of the serum potassium level. The nurse should check the client's reflexes and note any hyperreflexia or hyporeflexia, but these are not the priority assessments.

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Correct Answer is A

Explanation

Choice A reason: Paper mask and gown are considered regulated medical waste, which means they are contaminated with blood, body fluids, or microorganisms that pose a potential risk of infection¹. Therefore, they should be placed in a designated biohazard bag before they are removed from the room and treated according to the facility's policies and procedures².

Choice B reason: The nurse's stethoscope is not a disposable item and does not need to be placed in a biohazard bag. However, it should be cleaned and disinfected after each use to prevent cross-contamination³.

Choice C reason: Bed linens are not classified as regulated medical waste unless they are soaked with blood or body fluids¹. They can be placed in a regular laundry bag and washed according to the facility's guidelines.

Choice D reason: Sputum specimen is a type of microbiology laboratory waste, which is regulated medical waste¹. However, it should not be placed in a biohazard bag, but in a leak-proof, puncture-resistant container that is labeled with a biohazard symbol. This ensures the safe transport and handling of the specimen.

A. Lower the bed prior to helping the client to move up in bed. B. Encourage the client to eat all of the meals that are sent. C. Offer fruit juice at least twice during both the day and evening shifts. D. Have the client hold a pillow over the abdomen to cough and deep breathe.

Correct Answer is A

Explanation

Choice A reason: This is the most important instruction because lowering the bed reduces the risk of injury to both the client and the UAP. It also makes it easier for the UAP to use proper body mechanics and leverage when assisting the client to move up in bed.

Choice B reason: This is not the most important instruction because encouraging the client to eat all of the meals that are sent is not directly related to repositioning the client. While adequate nutrition is important for wound healing and recovery, the nurse should assess the client's appetite, dietary needs, and preferences before instructing the UAP to encourage the client to eat.

Choice C reason: This is also not the most important instruction because offering fruit juice at least twice during both the day and evening shifts is not directly related to repositioning the client. While adequate hydration is important for preventing constipation and promoting circulation, the nurse should consider the client's fluid status, blood sugar levels, and potential interactions with medications before instructing the UAP to offer fruit juice.

Choice D reason: This is another incorrect instruction because having the client hold a pillow over the abdomen to cough and deep breathe is not directly related to repositioning the client. While coughing and deep breathing are important for preventing respiratory complications and promoting oxygenation, the nurse should instruct the client to perform these exercises at regular intervals, not only when repositioning.

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When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

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Explanation

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